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HomeMy WebLinkAbout0052 SURREY LANE - Health 52 Surry Lane, Bamsta' ble MINE �9 f - ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e wM 52 Surrey Lane ,—• Property Address Natalie Galvin Owner Owner's Name ./ information is Barnstable y Ma 02630 11-9-16 required for every page. City/Town State Zip Code Date of Inspection 4W Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Matthew Gilfoy use the return Name of Inspector key. B&B Excavation ray Company Name 374 Route 130 Company Address r Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113640 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further.Evaluation by the Local Approving Authority 11-9-16 Inspector's Signature Date The system inspector shall.submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 ` �oe Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 52 Surrey Lane Property Address Natalie Galvin Owner Owner's Name information is required for every Barnstable Ma 02630 11-9-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System was in working order at time of inspection. Tank was pumped after inspection for maintenace B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 52 Surrey Lane 'M Property Address Natalie Galvin Owner Owner's Name information is required for every Barnstable Ma 02630 11-9-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Officia:Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 52 Surrey Lane Property Address Natalie Galvin Owner Owner's Name information is required for every Barnstable Ma 02630 11-9-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded ore clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System a Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 52 Surrey Lane Property Address Natalie Galvin Owner Owner's Name information is required for every Barnstable Ma 02630 11-9-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. w ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 52 Surrey Lane Property Address Natalie Galvin Owner Owner's Name information is required for every Barnstable Ma 02630 11-9-16 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ' ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,_excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (Actual) _2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form . _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 52 Surrey Lane Property Address Natalie Galvin Owner Owner's Name information is required for every Barnstable Ma 02630 11-9-16 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes Z No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): See below Detail: 2014-50,000gallons 2015-91,000gallons Sump pump? ❑ Yes*® No Last date of occupancy: Current Date Commercial/industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 52 Surrey Lane Property Address Natalie Galvin Owner Owner's Name information is Barnstable Ma 02630 11-9-16 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumper driver Was system pumped as part of the inspection? ❑ Yes ❑ `No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Tank size Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and, maintenance contract(to be obtained from system owner) and a copy of latest inspection of the i/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts ro Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Surrey Lane M Property Address Natalie Galvin Owner Owner's Name information is required for every Barnstable Ma 02630 11-9-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 7-14-1994 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction liner Town feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000gallons Sludge depth: 6 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 52 Surrey Lane Property Address Natalie Galvin Owner Owner's Name information is required for every Barnstable Ma 02630 11-9-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank was pumped after inspection for maintenance. Grease Trap (locate on site plan): Depth below grade: NAfeet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 52 Surrey Lane Property Address Natalie Galvin Owner Owner's Name information is required for every Barnstable Ma 02630 11-9-16 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Bolding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: . Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form —Not for Voluntary Assessments c,M 52 Surrey Lane Property Address Natalie Galvin Owner Owner's Name information is Barnstable Ma 02630 11-9-16 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was in working order at time of inspection but heavy carry over was present. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 52 Surrey Lane Property Address Natalie Galvin Owner Owner's Name information is required for every Barnstable Ma 02630 11-9-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: (1) 6'x6' ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching was in working order at time of inspection. Water level was 2' below invert with no higher staining. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'wM 52 Surrey Lane Property Address Natalie Galvin Owner Owner's Name information is required for every Barnstable Ma 02630 11-9-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. Privy (locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Surrey Lane M Property Address Natalie Galvin Owner Owner's Name information is required for every Barnstable Ma 02630 11-9-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately REAR GARAGE. DECK. A1:-2 ' 8 .71- *7 A2_35 132-61' G) t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Surrey Lane M Property Address Natalie Galvin Owner Owner's Name information is required for every Barnstable Ma 02630 11-9-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >10 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Heaith -explain: Previous inspection report where a hand hole was augured. ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Info on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 n • • J Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 52 Surrey Lane Property Address Natalie Galvin Owner Owner's Name information is required for every Barnstable Ma 02630 11-9-16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater' ® Sketch of Sewage Disposal System either drawn on page 15 or-attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 LOCATION`vl/ ''/ 3 0 SEWAGE PERMIT NO. VILLAGE INSTALLER'S NAME&ADDRESS c2 rAAC Co BUILDER OR OW E PJ DATE PERMIT ISSUED DATE COMPLIANCE ISSUED S 0' r I p THE COMMONWEALTH OF MASSACHUSETTS • APPROVED BOARD O� H E 1k H Zamsteble CormrntWn Depanm id TOWN OF Y2N H /F Sign p# iratinn r spasal Works Tonstrurtiun rrrmit Application is hereby made fora Permit to Construct ( ) or Repair (�an Individual Sewage Disposal System at• C ............ _ �vrz!? ................................... ...................... Z y8--off/......_.._..._............. CLI t' n- ress -or Lot No. W .. � .._ Owner .......................... l..Y1!^...... . !X...... Address......_......_.................~�..... .. ...................................................... a Installer Address Type of Building Size Lot................ Sq. feet ........... U Dwelling—No. of Bedrooms.- _Expansion Attic ( ), Garbage Grinder ( ) '4 Other—T e of Building No. of persons............................ Showers — Cafeteria a Other fixtures d --•-------•-•--•..............................•---_....-•-........_----- W Design Flow............................................gallons.per person per day. Total daily flow__________.......___....._..................gallons. WSeptic Tank—Liquid capacity............gallons, Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by................... ....................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth.of Test Pit.................... Depth to ground water........................ a ...... ...--•--------------------------------•-•---...................................-.._.....-............................----...._.................... ODescription of Soil....................................................:.................................................................................................................. V ..................... _------•-----........._...-•-•--- ........... ......._..... ._._.... ...................... ---------------------•-••--------•----...__......------------.....-------•----......-------------•------.......--•-•-•-----------.............,.................................................... U Nature-of Repairrr Alterations—Answer when '--. !.S_.G-------- ....I..CFt7f/._ .1i.1.... A1e�'.... .L?...'...�j. C.....•.. .............. Agreement: The undersigned agrees to install the aforedescribed. Individual Sewage Disposal System in accordance with the provisions of iITL M 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued b the board of health. Signed. .--- �..... ... .............................................. ................................ � a Application Approved By `..� ...----•..................... Date Application Disapproved for the following reasons:.........................................................................................- .___......__ ................................................................................................................................................................................... •----•---.... Date PermitNo...... ......._.s�--s—Z........_.... Issued................ ...................................... Date ____; _YL�__.,# . ,his-St+'^Y7�`"",.,r•y„'.�r�..r<'7,,,.`. 'g"�+ `b�» r *l- 'ifjil„�"`++"Ff"'�`T'p'"",� - 1,y�••�'re'' tf�•rf•3�t' .. r7?l`r`,r ryY . lK.r,.�v. No... � .�-� (� ...F$sU.. ........_ - THE COMMONWEALTH OF MASSACHUSETTS `$ BOARD OF HEAppLTH TOWN OF Y&W-ROUTH Appliration for Disposal Works Tonstrurtion rrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ✓ an Individual Sewage Disposal System at: ....._ .» ..............Locatio:A dress.................................. ..... ......................- or Lot No....... .._............ ..».»..... W •-�- ��� /' , Owner •-- ---- •-- Address ........................... ------ _. l�___r_�J....................._.................................... Installer Address Type of Building � „„rSiae Lot............................Sq. feet ,.., Dwelling—No. of'Bedrooms.._..................................Expansion Attic ( ) '(Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers i — Cafeteria Q' Other'fixtures ---•................•-••-•..................... WW Design Flow......:.....................................gallons per person per day. Total daily flow............................................gallons. W Septic Tank—Liquid capacity_.......__..gallons Length................ Width................ Diameter................ Depth.......... . x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft. , 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area................sq. ft. z Other Distribution box ( ) Dosing tank ( ) ` Percolation Test Results Performed by.......................................... Date......:................................. Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fi Test Pit No. 2.......I..........minutes per inch Depth of Test Pit.................... Depth to ground water........................ R+' ••-•---•--•----••••••._....--•••-•..................................................••-______-••••..........._....._...-•--•••-•-•••--•--••••........_....._. 0 Description of Soil..........................•---.............--•----•---•-•-•--.......__..............-•-•--------.........................---..........-----...._._..................._.. V ..................... ........ ................... •••••.............. ........... -.................. __-••-••-•-•-••--.._................ �.� W •••---------•••-••------------ -•••••-•-•-•......_...--------•-•-•...•-•...••---••-................_---••--•--._...._-----------.._............;........................---••-•-....._--•---•-•••_•-•--• UNa re of Repairs or Alterations—Answer when applicable_.Zkl_._/.F' .ail-/.1'�!•:1_`...�'___. fi P__3 !z1.:/.�..1.._.7,�.L....'--:rs.:..�.c�-`�------•-•------........ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed. ./._._C�_ /I raU' `1 1 Date Application Approved By..........i ............................................ ._...... ..-. -. Date Application Disapproved for the following reasons:..............................._______-_... ..................._....-_______....._...________.......»» ...............•---..............---.........--------....-•---...........----...--------.......----•----•._.........--•'••--••---•-••---.............._._....................._......__••-•-•---•-••-••-= ,,•.--^^ Date PermitNo....... -..... .:?_..6............. Issued.........»--... ...:..---............................. Date THE COMMONWEALTH OF MASSACHUSETTS ABOARD O��AFL/THh�� `TOWN of YROJ®�H f�rrtif trtttr of f�om�Itttnr�e � THIS IS TO CERTIFY, That Pe Individual Sewage Disposal System constructed ( ) or Repaired ( v� by............................ ........................ -..............................................» , Installer 1 ) at_........ .-•--:rL-& _`......1-.,4.................' ? .Y?.1 e .......:.................. / �'- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.......�.1,�.�_�,.:.....�'�-�:...... dated----------------------------•----._.._... .. ,M , Y� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. � ������L�_ DATE.......... .. '`'"`. ....` ... � ....... Inspector........ - ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH/ TOWN�'of�A- UTI No...... �/••-;, � / Fs$........................ �" Otsposaj nrks Tonstrudiun rrrutit . Permission is hereby granted............1..............nU a........___- ...................................................:..........................».... < to Construct ( ) or Repair ( a an Individual Sewage Disposal System atNo....... ........ ........................: Street as shown on the application for Disposal Works Construction Permit No..,/_:y.... Dated........ - u t Board of Health DATE.................... No. r / Fas.............................. T . L . �l THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE TH TH 0F..Wg�". .�.� .............................. (� Appliration -fur Biiipoiial Wor!�or owitrurtion Vamit Application is hereby made for a Permit to Construct ( Repair ( ) an Individual Sewage Disposal SysterR at.,, - 5 �-3® -- --- A lotion•Add ss �s I f� �+ ..................Lot No. K• r Address WW1 ••••.................... ......... Installer Address d Type of Build" Size Lot............................Sq. feet V Dwelling l"No. of Bedrooms---------��.�-------------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ____________________________ W Design Flow______________--6-V..................gall s p rerson per day. Total daily flow.....___�®_..�__---.-_.-.-_----gallons. P4 Septic Tank—Liquid capacityla gall i"L�ftgth---------------- Width-----_-...._-- Diameter-............... Deptli.-.---------_-- Disposal Trench—No.............T .. Width___________ __ Total Length.................... Total leaching area-------------.......sq. ft. x Seepage Pit No___________ ________ Diameter_jb�9..�'-Depth below inlet___.___._......._._. Total leaching area_.-_-.-.-.._.--___sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by------- ------------------•--•--------•------••--•---•--.........._. ••-- Date........................................ Test Pit No. 1_______________minutes per inch Depth of "Pest Pit...........--------- Depth to ground water..--__-_-----.-------.-. Test Pit No. 2................minutes per inch Depth of Test Pit---_-_---_-______- Depth to ground water-......________.__-_---. ------------------- ......................................... .__ ................ - ::. W UNature of Repairs or Alterations—Answer when applicable._.__........................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code—The undersi ned further agrees not to place the system in operation until a Certificate of Compliance has been ' s by the bo health. / 4 r/ Signed_ w / �---- f - ----------- -------- ----------------------------- Application Approved By---' --- -- ------------- -------------------•---------- --.------ Date Application Disapproved for the following reasons:..... ----------------------•-........................................................ •-----•••--•-•---•--•-•-----•---------------•------------------------••- -•------•••--••-----•••-•-------------••-••--•-•••----•-------••------•---•---•-•-••-----.................................... Date PermitNo--------------------------------------------------------- Issued...... - --�"- ate Fug g�...�......._ THE COMMONWEALTH OF MASSACHUSETTS ROAD® OF HEA NTH . pptirtttinn -for Uiiipu,itt1 Workii Tomitrurtion Permit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at Ll " -------3------. r�R--------------- cation-Ad�ess ��{ O�G„ � .�+ or Lot No. ......................... M1...... ..............�..f...(.7------. -.-- ----------------------------------------- ...Aaaress.. w �..I j ---------------------- -------------------------------------------------------------------------------------------------- Installer Address UType of Building Size Lot----------------------------Sq. feet Dwelling—�No. of Bedrooms--------Z-............................Expansion Attic ( ) Garbage Grinder ( ) Ga, Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ................................ W Design Flow............. ..................gall p r person per day. Total daily flow-------- o_.U-_.-----------__.-.gallons. WSeptic Tank—Liquid capacity1©�__gal or;'K�ngth________________ Width__.._.___... Diameter................ Depth.__.--._-_--- x Disposal Trench—No ____________________ Width------ _______ Total Length------------_....... Total leach_ng area.................... ft. Seepage Pit No-----------f-------- Diameter-60o Depth below inlet------------------- Total leaching area-------.----------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by--------------------------------------------------- ...................... Date....................................... a Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water..-.--._.--.--..--.-_._- Test Pit No. 2________________minutes per inch Depth of Test Pit-------------------- Depth to ground water--.._.-..--.-__.____.--- W0 Description of Soil---------------------------=-"" '----------------- ------- ----- ---------------------------------------------------------------------------------- X -•------------•-•------ ............ -------------------�'z..-'-=`--....------ --- `""' -------------------------------•----.•-•--••----•------------. -- W ------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ UNature of Repairs or Alterations—Answer when applicable.-__________________________________________________________________________________________ _- ------------------------------------------------------------------------------------------•----------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue- by the board health. r %-If," Si ed '� !.�....-`'�u.. .-r-------------------- �--------- 41— ate Application Approved By..-- -- ,-- -- Date Application Disapproved for the following reasons------------------------- --------------------------------------------- ----------- --- - ------------t---------- - -- ------- Dae PermitNo......................................................... Issued.......!. L.J....7 .................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �c.....................OF.... �ti!- .'........ ............................. 101rrtif irtttr of fITILImplittnrr THIS ISITO CERTIFY hat e Individual Sewage Disposal System constructed (,X) or Repaired ( ) Installer at--------- =�' �� vZ_�� �.------•--...------------------------------------------------- has been installed in accordance with the/rovisions of Article XI of The State Sanitary Code/as descri ed in the application for Disposal Works Construction Permit No________________ ___ _ dated___.. �✓2..G ... _ ........ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GU RANT E T-KXT'THE SYSTEM WILL FUN ION SATISFACTORY. DATE y�-------------------•-------- Inspector -- ------- 1 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .,�........ti,......OF......c... '!'? :... ........................................... �. No.-._�... 3------. ', FEE....2.:.............. n � ,itrjtrtion Permit Permission is hereby granted....¢FAQ- t' �� " r ----------------------------------••-•----------••----•---------•---•----- to Construct ( or Repair ( ) n Individual Sewage Disposal stem atNo. -?-' n - __-------------------------------------------- -------- ------------------ Street � �7 as shown on the application for Disposal Vorks Construction Per it No. . ............. .. Dated.... a: �_ . ' ------•------ Board df'Health DATE.......... ------------------------- / FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS / �{tl a r i �,.S � .,. ..-::.-• « 1. . ^yw'F't4w«+?Fi•n .:,:,r. �� ,rtj ssessor's map and lot number ! ��' p / f v[�lea , rA ..... •.i. .... 1�"r" Ilr SYSTEM �.1 I M Ml3ST° titer r — ........ IN STAI LED y CjV�P-•iL PgNC .wage Permit4number Anl 8N_ ....., .. .. 31.� ' Id e�`I,11•�l~ ;:.' �t i tZ SANITAIR c UE ANCi" ' HE VX WsE tQ�Nt r ® InP /A�®� l a t ' r i BARaSTA 3L • t i i M6 9 BUK" INGINSPECTOR �. APPLICATION FOR PERMIT TO ;:. j!-a /r►//y///^/ TYPE OF CONSTRUCTION ....M. 'lG?7, ' r r ................... TO .THEANSPECTOR OF BUILDINGS-3 The undersigned hereb lis fora `9 / ya ppe ry permit according to the following information: Location ........... . p s J fL✓L� ...... .. ... .............................................. ... „ . . ' Proposed Use G' Zoning District `• 3 ' •••.. .Fire District 15vzsr.��pG Name of-Ownercc %cc //- '. J. Address .... Name of Builder , a Address Name of Architect I t Add ' I w � .. : ::. ..: .:.: ress V ` Number:of Rooms r` *r ' r .. Foundation Ez1ei for ; e47;e'?4.4. .Roofing f-...... Floors' 4C?1M` t Interior / > C. '') /1 : .. Heating b.0.•� ,;;"��..�,�, ,1. p'�. `�`•'f�T L-,�rr. PI l..c�/++p•� Pl!'�: •4 f�.ffW, ,. " ', , W umbing 73. w Fireplace Approximate Cost' a Fri " f pP ( ... ' 1$ t' Definitive Plan Approved by Planning Board �.'_ _�_-_ ;I t q , Area, ti i Da ram{ g of Lot and Building with Dimension , y� r r r, Fee ,,4;_,-�..¢ :3.;�• ,� t r BOARD OF HEALTH t' " SUBJECT;TO APPROVAL OF r L1At.V` o i� . t y V p•� /�Vy C� •/� t�t+�j`� � - 4•.. I0, � .JL�T�(•, `iTly� � t,� ildi` it.f 7 � � t it k Y jMiy', � '� � I f1�� •{(� 1 p 'A .til. ' 1F"a. a .r � � a•, °�" is "*+. �' �"'� �.? .S " 3 � +J , 3�S � Jar , # ,♦� ��, '� "t y A',' #�. 3 �- 1� � - r 4dtii?t, }v.��f 5 , r , w R # I he agree to conform to all the Rules and Regulations of the Town of Barnstabl egarding the above4! construction. Name ..!'".,�% .. ... , .`'!.�---�,..J.. `'� ;P0 �y 4. f ........ 4 I!' i'�1 r.'• •, �,.>i '..�.`- rh"`�`""�,..,. ' --—T - .s.+. ': r r`rpx" :{ "'f ny. �r. —•t ���' 7`l.' k`' r�"�t�.x�• uR;'.